Provider Demographics
NPI:1114730074
Name:HENDERSON, LACEY
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 ROUTE 2
Mailing Address - Street 2:
Mailing Address - City:HERMON
Mailing Address - State:ME
Mailing Address - Zip Code:04401-0609
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2423 ROUTE 2
Practice Address - Street 2:
Practice Address - City:HERMON
Practice Address - State:ME
Practice Address - Zip Code:04401-0609
Practice Address - Country:US
Practice Address - Phone:207-742-2839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN54403163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse